Cell Rich Toxic Epidermal Necrolysis (TEN): A Novel Histological Variant with Prognostic Implications
Jodi J Speiser, Vikas Mehta, Kelli A Hutchens. Loyola University Medical Center, Maywood, IL
Background: Toxic epidermal necrolysis (TEN) is a desquamating dermatosis defined by >30% body surface involvement combined with full thickness epidermal necrosis on histology. Mortality for TEN reaches 40% despite therapy. Therapy modalities are controversial and range from supportive care only to administration of intravenous immunoglobulin and / or high dose steroids. Classic histology is a cell poor subepidermal blister with full thickness epidermal necrolysis. The histologic spectrum of TEN and its relation to clinical outcome has not been previously examined. Here we describe a frequently encountered cell rich variant of TEN and compare its outcome with the classic pauci-cellular type.
Design: We analyzed the histologic findings on 23 cases of TEN. All cases were clinically consistent with TEN and were treated with the same standard protocol (supportive care only) at the LUMC burn unit. Cases were grouped into either cell rich variant, demonstrating full thickness epidermal necrosis with a dense lichenoid infiltrate, or the classic cell poor variant. Clinical hospital courses within one week of biopsy were evaluated and separated by complete recovery or morbidity/mortality.
Results: 16/23 cases were pauci-cellular and 7/23 were cell rich. 10/16 pauci-cellular cases had significant morbidity / mortality (5 morbidity and 5 mortality). 6/7 cell rich cases had a complete recovery and 1/7 case resulted in mortality. There was a higher correlation of significant morbidity / mortality with the cell poor variants than the cell rich variants [p=0.03 (Pearson's chi-squared test)].
Conclusions: The cell rich form of TEN has not been previously well described and could be diagnostically challenging for the pathologist. Due to the high mortality and morbidity of TEN, it is imperative that pathologists are aware of both the cell poor and cell rich variants. Additionally, our study indicates that histological cellularity may be a prognostic indicator. Separation TEN by histologic variant is novel and may also be the missing link needed to align current therapy algorithms.
Monday, March 4, 2013 9:30 AM
Poster Session I Stowell-Orbison/Surgical Pathology/Autopsy Awards Poster Session # 69, Monday Morning